Acute Gastroenteritis: Adult ______Gastrointestinal

Home , Acute (medicine), Blood in stool, Colitis, Enteritis, Gastroenterocolitis

Clinical Decision Tool for RNs with Effective Date: December 1, 2019 Authorized Practice [RN(AAP)s] Review Date: December 1, 2022

Background Gastroenteritis, also known as enteritis or gastroenterocolitis, is an inflammation of the stomach and intestines that manifests as anorexia, nausea, vomiting, and diarrhea (Thomas, 2019). Gastroenteritis can be acute or chronic and can be caused by bacteria, viruses, parasites, injury to the bowel mucosa, inorganic poisons (sodium nitrate), organic poisons (mushrooms, shellfish), and drugs (Thomas, 2019). Chronic causes include food allergies and intolerances, stress, and lactase deficiency (Thomas, 2019). Gastroenteritis caused by bacterial toxins in food is often known as food poisoning and should be suspected when groups of individuals present with the same symptoms (Thomas, 2019). Immediate Consultation Requirements The RN(AAP) should seek immediate consultation from a physician/NP when any of the following circumstances exist: ● moderate dehydration (six to 10% loss of body weight), and blood pressure and mental status do not stabilize in the normal range within one hour of initiating rehydration therapy; ● severe dehydration (>10% loss of body weight); ● high fever and appears acutely ill; ● tachycardia or palpitations; ● hypotension; ● severe headache; ● blood or pus in stool; ● severe abdominal pain; ● abdominal distention; ● absent bowel sounds; ● altered mental status; ● older and immunocompromised clients; and/or ● severe vomiting (Interprofessional Advisory Group [IPAG], personal communication, October 20, 2019).

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The RN(AAP) should initiate an intravenous fluid replacement as ordered by the physician/NP or as contained in an applicable RN Clinical Protocol within RN Specialty Practices if any of the Immediate Consultation circumstances exist.

Classification of Gastroenteritis

Infectious Non-infectious

Acute gastroenteritis is most often caused by Acute gastroenteritis can also be caused by an infectious agent. The most common mode dietary factors, medications, and metabolic factors of transmission is the fecal-oral route from such as: contaminated food or water (Thomas, 2019). ● coffee, Bacterial pathogens cause approximately 30 ● tea, to 80% of cases. Viral, and parasitic ● sodas containing caffeine, pathogens may also cause gastroenteritis ● antacids, (Huether, 2019). ● antibiotics, Common causes may include: ● diabetes mellitus, Bacterial: ● hyperthyroidism, ● Campylobacter jejuni ● adrenal insufficiency. ● Shigella ● Salmonella ● Enterohemorrhagic Escherichia coli ● Clostridium difficile (C. difficile) Viral: ● Rotavirus ● Norovirus virus Parasitic: ● Giardia lamblia ● Cryptosporidium (Huether, 2019; Thomas, 2019) Predisposing and Risk Factors Predisposing and risk factors for acute gastroenteritis in adult clients include: ● recent travel to developing countries, ● immunocompromised clients, ● anal intercourse, ● residents of institutions or nursing homes, ● consumption of raw shellfish and seafood, ● consumption of contaminated food or water, ● crowded living conditions, and/or ● antibiotic and/or antacid use (Thomas, 2019).

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Health History and Physical Exam

Subjective Findings The circumstances of the presenting complaint should be determined. These include: ● onset (abrupt or gradual) and duration of symptoms; ● alleviating or provoking factors; ● contact with someone with similar symptoms; ● degree of nausea, vomiting, and diarrhea; ● fever; ● abdominal pain or cramping; ● fatigue, malaise, anorexia, tenesmus, borborygmus (presence of symptoms depends on underlying condition); ● symptoms of dehydration; ● characteristics of feces (frequency, amount, fluidity, and colour); ● diet history, including food intolerances; ● recent travel; ● exposure to animals (e.g., reptiles which may harbour Salmonella, pets with diarrhea, or a recent visit to a farm or petting zoo); ● source of drinking water; ● intake of untreated water (e.g., swimming in a stream or lake); ● medications (e.g., antibiotics, antacids); ● medical/surgical history; ● sexual practices, including anal intercourse; ● social history, including living conditions, illicit drug use, alcohol use; and/or ● family history (e.g., colon cancer, inflammatory bowel disease) (Thomas, 2019).

Objective Findings The physical examination is usually normal in adults presenting with acute gastroenteritis, except for the gastrointestinal symptoms identified in Subjective Findings section (Thomas, 2019). The physical examination should look for signs of dehydration including: ● altered mental status; ● decreased capillary refill; ● decreased skin turgor which is tested on inner aspect of thighs or the skin overlying the sternum, and is less reliable in older clients due to decreased skin elasticity with age; ● dry mucous membranes of the tongue and oral mucosa;

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● orthostatic hypotension, which is determined by taking supine blood pressure after the client is laying down for five to 10 minutes, and then taking the blood pressure as soon as the client sits or stands up, and again in this position after two to three minutes. A drop in systolic blood pressure ≥ 20 mmHg or a drop in diastolic blood pressure ≥ 10 mmHg from supine indicates orthostatic hypertension; and ● weight loss (Sterns, 2017).

The RN(AAP) should be cognizant that: ● classical signs of dehydration such as loss of skin turgor, increased thirst, and orthostatic hypotension have a low sensitivity in older adults. ● dehydration may cause atypical symptoms such as confusion, constipation, fever, and falls (Hooper, 2016; Huang, 2018; Sterns, 2017).

The following table can assist in determining the level of dehydration in adult clients, noting that moderate and severe dehydration require immediate consultation to a physician/NP.

Physical Findings in Association with Degree of Dehydration

Clinical Sign Mild Dehydration Moderate Severe Dehydration Dehydration

Estimated fluid loss (% of < 6% 6-10% > 10% body weight)

Level of consciousness alert lethargic obtunded or comatose

Capillary refill 2 sec 2-4 sec > 4 sec, cool limbs

Mucous membranes normal dry parched, cracked

Heart rate normal or slightly increased very increased increased

Respiratory rate/pattern normal increased increased and hyperpnea

Blood pressure normal normal, but decreased abnormal orthostatic

Pulse normal thready faint or impalpable

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Skin turgor (over sternum normal slow tenting or inner aspect of thigh)

Eye appearance normal sunken very sunken

Urine output decreased oliguria oliguria/anuria (Huang, 2018) Differential Diagnosis The following should be considered as part of the differential diagnosis: ● viral infection, ● bacterial infection, ● parasitic infection, ● diet induced (e.g., excess consumption of alcohol or fruit), ● medication induced (e.g., current or recent antibiotic use, laxatives, supplements), ● irritable bowel syndrome (IBS), ● inflammatory bowel disease (Crohn's colitis, ulcerative colitis, ischemic colitis), ● ischemic bowel disease, ● partial bowel obstruction, ● pelvic abscess, ● malabsorption syndrome (e.g., lactase deficiency), ● acute psychosocial stress/anxiety, ● any surgical alteration of the GI tract, or ● complications from diabetes mellitus, small bowel diverticulosis, Whipple’s disease, or chronic pancreatitis (Thomas, 2019). Making the Diagnosis Systematically ruling out all differential diagnoses through history, physical, and diagnostic testing where appropriate can help lead to a definitive diagnosis. Caution should be exercised in making the diagnosis and attributing gastrointestinal symptoms only to acute gastroenteritis. The following table may help identify the diagnosis.

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Clues to Underlying Etiology

Sign or Symptom Potential Cause

Bloody stool Bacterial pathogen such as: ● Shigella ● Salmonella ● Campylobacter ● Enterohemorrhagic Escherichia coli

Symptoms present after eating hamburger meat E. coli

Persistent diarrhea (> 2 weeks) ova and parasites

Recent travel to Russia, Nepal, Rocky ova and parasites Mountains or other mountainous regions

Exposure to infants in a daycare centre ova and parasites

Men who have sex with men ova and parasites

Symptoms after initiation of antibiotics and the C. difficile month following completion

Vomiting as main symptom viral pathogen

Suspected food or waterborne contamination viral pathogen

Frothy stools and flatus malabsorption (Thomas, 2019) Investigations and Diagnostic Tests Laboratory tests are not usually necessary in clients with non-bloody diarrhea and no evidence of systemic toxicity (Thomas, 2019). Selection of the appropriate tests is based on the history and physical exam (Thomas, 2019) as well as through consultation with a physician/NP, as in most cases clients requiring testing are acutely ill. Stool testing for culture and sensitivity, ova and parasites, and C. difficile toxin, may be considered in clients with severe bloody diarrhea, fever of ≥ 38.5°C and symptoms on return from travel (Thomas, 2019).

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Management and Interventions

Goals of Treatment The primary goals of immediate treatment are to identify the cause, relieve symptoms, prevent complications (e.g., dehydration), and prevent transmission if the cause is determined to be infectious.

Non-Pharmacological Interventions All clients who present with diarrhea require fluid and electrolyte management, particularly older adults and those who are immunocompromised. Refer to the SRNA Dehydration Adult Clinical Decision Tool for information on rehydration and oral rehydration solution.

The RN(AAP) should recommend, as appropriate, non-pharmacological options: ● dietary adjustments (avoid sorbitol, xylitol, lactose, or known food triggers); ● stop solid foods for a brief period (six hours) or eat small frequent meals slowly throughout the day if stool is frequent and watery or if vomiting occurs in association with diarrhea; ● drink eight to 10 cups of fluid per day through a combination of clear broths, oral rehydration solutions (e.g., Gastrolyte), and a modest amount of hypotonic fluids (water, half-strength juices, weak tea); ● resumption of a normal diet as soon as tolerated; ● limit fried or fatty foods, and foods high in sugar; ● add sources of soluble fiber to bulk up stool; and ● avoid coffee, alcohol, most high fiber fruits and vegetables, red meats, and heavily seasoned foods initially (Gastrointestinal Society, 2018; Huether, 2019; Rx Files Academic Detailing, 2017).

Pharmacological Interventions The pharmacological interventions recommended for the treatment of diarrhea are in accordance with the RxFiles: Drug Comparison Charts (Rx Files Academic Detailing Program, 2017), Acute Diarrhea (Barr & Smith, 2014), and Infectious Gastrointestinal Disorders (Thomas, 2019).

Pharmacological interventions are available to relieve symptoms, but routine use is discouraged when an infectious cause is suspected. Over-the-counter pharmacological options might be appropriate in the following mild to moderate cases only: ● an otherwise healthy adult,

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● no fever, ● less than two days duration, and ● no blood in stool.

Anti-diarrheal Agents Symptomatic treatment of acute diarrhea can decrease its occurrence by 50% and is most effective against secretory diarrhea. Antimotility drugs are the most frequently prescribed and most effective for symptomatic treatment of gastroenteritis. These drugs work by slowing intraluminal peristalsis thereby slowing passage of fluids through the bowel, facilitating absorption (Thomas, 2019).

Drug Dose Route Frequency Duration

Adult

Bismuth 30 mL or 2 tabs p.o. q30 minutes prn 1-2 days subsalicylate to a maximum of 8 doses/day

OR Loperamide 4 mg then 2 mg after p.o. 4 mg once and 1-2 days each loose bowel then 2 mg after movement each bowel (maximum of 16 mg movement 8 tabs/day)

Antiemetics

Drug Dose Route Frequency Duration

Adult

DimenHYDRINATE 25-50 mg IM/IV once n/a

THEN DimenHYDRINATE 50 mg p.o. q4-6h prn 1-2 days

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Antispasmodic May help relieve abdominal cramping.

Drug Dose Route Frequency Duration

Adult

Hyoscine 20 mg IM/IV once n/a butylbromide

Client and Caregiver Education The RN(AAP) provides client and caregiver education as follows: ● Counsel about the appropriate use of medications (dose, frequency, side effects, compliance, etc.). ● Inform that proper hand washing and safe disposal of waste products prevents the spread of infection (Thomas, 2019). ● Share strategies on how to prevent recurrent diarrhea (e.g., water purification as appropriate, which is to boil water for 20 minutes or use chlorine tablets or solution). ● Consume only safe food and beverages when traveling to high-risk areas (e.g., acidic foods such as unpeeled citrus fruits; dry foods such as breads and cereals; steamed foods and beverages; foods containing high amounts of sugar; bottled carbonated drinks) (Thomas, 2019). ● Recognize signs and symptoms of dehydration and to return to the clinic if they occur. ● Advise to temporarily discontinue any medications associated with diarrhea, if possible. ● Recommend witch hazel cotton pads (e.g., Tucks) and/or zinc oxide ointment, which may provide relief to the raw perianal area (Barr & Smith, 2014).

Monitoring and Follow-Up The RN(AAP) should: ● Monitor hydration, general condition, and vital signs until stable. ● Advise follow-up in 24 hours (sooner if oral intake is not keeping up with losses) and encourage fluid intake after rehydration. ● Ensure adequate follow-up of hydration and nutritional status, especially in elderly clients.

Complications The following complications may be associated with acute gastroenteritis:

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● dehydration, ● electrolyte imbalance, ● metabolic acidosis, ● aspiration pneumonia, ● perforated esophagus, and ● weight loss (Huether, 2019).

Referral Refer to a physician/NP if client presentation is consistent with those identified in the Immediate Consultation Requirements section, where there is diagnostic uncertainty, or who has not responded to treatment (IPAG, personal communication, October 20, 2019).

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References Barr, W., & Smith, A. (2014). Acute diarrhea. American Family Physician, 89(3), 180–189. Gastrointestinal Society. (2018). Diarrhea and diet. Retrieved from https://badgut.org/information-centre/health-nutrition/diarrhea-and-diet/ Hooper, L. (2016). Why, oh why, are so many older adults not drinking enough fluid? Journal of the Academy of Nutrition and Dietetics, 116(5), 774–778. doi.org/10.1016/j.jand.2016.01.006 Huang, L. (2018). Dehydration treatment and management. Retrieved from https://emedicine.medscape.com/article/906999-treatment#d9 Huether, S. (2019). The cellular environment: fluids and electrolytes, acids and bases. In K. McCance & S. Huether (Eds.), Pathophysiology: The biologic basis for disease in adults and children (8th ed., pp. 104-132). St. Louis, MO: Elsevier. Rx Files Academic Detailing Program. (2017). Rx Files: Drug comparison charts (6th ed.). Saskatoon, SK: Saskatoon Health Region. Sterns, R. (2017). Etiology, clinical manifestations, and diagnosis of volume depletion in adults. Retrieved from www.uptodate.com Thomas, D. J. (2019). Infectious gastrointestinal disorders. In L. Dunphy, J. Winland-Brown, B. Porter, & D. Thomas (Eds.), Primary care: The art and science of advanced practice nursing – an interprofessional approach (5th ed., pp. 544-565). Philadelphia, PA: F. A. Davis.

NOTICE OF INTENDED USE OF THIS CLINICAL DECISION TOOL

This SRNA Clinical Decision Tool (CDT) exists solely for use in Saskatchewan by an RN with additional authorized practice as granted by the SRNA. The CDT is current as of the date of its publication and updated every three years or as needed. A member must notify the SRNA if there has been a change in best practice regarding the CDT. This CDT does not relieve the RN with additional practice qualifications from exercising sound professional RN judgment and responsibility to deliver safe, competent, ethical and culturally appropriate RN services. The RN must consult a physician/NP when clients’ needs necessitate deviation from the CDT. While the SRNA has made every effort to ensure the CDT provides accurate and expert information and guidance, it is impossible to predict the circumstances in which it may be used. Accordingly, to the extent permitted by law, the SRNA shall not be held liable to any person or entity with respect to any loss or damage caused by what is contained or left out of this CDT.